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What is menstruation and how it happen?
Menstruation is the periodic (once in a month) bleeding which happens to all the women from puberty to menopause. This is the manifestation of internal hormonal cycle within female body which is needed to produce an egg every month from the ovaries. The eggs get matured gradually and ultimately only one egg reach the complete maturation to burst out from the ovary (ovulation). This is result of complex interplay of different hormones and chemical substances. Although it is true that ovulation occurs in the middle of two menstrual bleeding but calculating fertile days for intercourse to get pregnant and calculating “safe days” to avoid pregnancy should be discouraged as it causes too much mental anxiety.
What is PMS( premenstrual syndrome ?
PMS is a group of symptoms linked to the menstrual cycle. PMS symptoms occur 1 to 2 weeks before your period (menstruation or monthly bleeding) starts. The symptoms usually go away after you start bleeding. PMS can affect menstruating women of any age and the effect is different for each woman. For some people, PMS is just a monthly bother. For others, it may be so severe that it makes it hard to even get through the day. PMS often includes both physical and emotional symptoms, such as:
•Acne •Swollen or tender breasts •Feeling tired •Trouble sleeping •Upset stomach, bloating, constipation, or diarrhea •Headache or backache •Appetite changes or food cravings •Joint or muscle pain •Trouble with concentration or memory •Tension, irritability, mood swings, or crying spells •Anxiety or depression •suicidal thoughts •uncontrollable anger
Combinations of symptoms vary from woman to woman. If it is really bad with more than five symptoms (strong propensity to emotional symptoms) it is called PMDD.[Premenstrual Dysphoric Disorder]
Many women do not need any treatment at all apart from some life style modifications like some exercise and avoiding some sugary & salty food. Sometimes simple analgesic is needed. Many women also find benefit by different supplement like multivitamins ( vitamin B, Vitamin E, VitaminD and others), evening primrose well, chestnut extract, black cohosh etc. Women who have terrible unbearable PMS need to visit gynecologist as hormonal medications which stop ovulation can really help. Women with features of PMDD may need selective serotonin reuptake inhibitors (SSRIs) but this can only be given after trial of other medications.
Pre –pregnancy gynecological consultation
Time before conception is really important as an woman can only know about pregnancy when she misses a period but pregnancy is conceived about two weeks before that .Patients with previous medical disease like epilepsy, diabetis, high blood pressure, auto-immune disease must consult a good gynecologist before contemplating a pregnancy. Nutrition status, avoidance of environmental toxic material, checking for rubella immunity, any pelvic infection, blood sugar level, haemoglobinopathies etc must be checked before pregnancy.
Pre marital gynecological consultation:
Most people do not come to gynecologist before marriage. Pre marital consultation is good practice because only good gynecologist can discuss about the safe and proper practice about sex life and preparation towards pregnancy. Checking for haemoglobinopathies (e.g. Thalassemia), different sexually transmitted & pelvic infection for both partners must be must be undertaken before two young partners unite for life to enjoy the marital bliss.
Emergency Contraception :
Emergency contraception is the measure to prevent pregnancy after sexual intercourse. It must be used within 72 hours of intercourse. Earlier it is used better the success in prevention of pregnancy. It is safe and does not have any longterm problem associatated with it. However, it should not be used as a substitution of regular contraception and to be used in emergency situation only.
Remember, only abstaining from (avoiding) all sexual contact offers 100% protection from pregnancy. If you are involved in sexual contact and you do want to get pregnant you need to use some method of contraception. However, different people like different things and that’s why different types of contraception is available. You should discuss about the options of contraception openly with a gynaecologist according to your sexual behavior and your likings.
Many couple use withdrawal or calendar method but they not only carry high risk of getting pregnant but also these may cause female sexual problems. This is the reason your gynecologist will not recommend these.
Recommended contraception methods include condom, oral combined pills, mini pills, injectable contraceptions, Intra uterine Cu T, intrauterine mirena and vaginal ring devices. Your ideal contraception should be decided by a confidential discussion with a gynecologist and following discussion is only for guidance.
Permanent contraception is sterilization. Sterilization is an irreversible process and further childbearing is not possible once sterilized. Female sterilization is by bilateral tubal ligation- can be done by open or laparoscopic method. No Cut No hole sterilization for female is also possible but costly in Indian standard at this moment. Male sterilization is called vasectomy and technically easier than female sterilization. I must stress on the fact that male or female sterilization does NOT hamper sexual experience, working power or vitality.
Condom & other barrier contraceptive :
Good thing about condom is that it prevents sexually transmitted disease together with contraception. Condom is a must (even if there is other contraceptive method available) if you are engaged with sexual activity with a stranger. If properly used condom is 98% effective. Female condom & diaphragm are barrier contraceptive for female but only rarely used in Kolkata & eastern India.
Oral combined pills
This is very effective and commonly used contraception method. This pills contain small doses of oestrogen and progesterone. These pills may be used for long period of time and actually confers some health benefit regarding other gynecological problems. These pills regularize menstrual pattern, prevent ovarian cyst formation and may prevent endometriosis. But , most women are very concerned because of nausea it causes at 1st few months. It may not be suitable with some ladies with risk factors of some medical problems. ( aged , obese, migrane, liver disease, smokers, etc.) These are available free of charge from Govt. health centres.
Pills without estrogen (Mini pills):
these pills do not contain any estrogen hormone and can be used safely with many patients with medical risk factors. It is also safe to take during breast feeding. However, these pills need to be taken more punctually than combined pills and missing even one pill increase the risk of pregnancy substantially.
Intra uterine Cut:
This is a small plastic device containing some copper filament which slowly get released in the intrauterine environment and prevent implantation of pregnancy. It is cheap & freely available from the govt. health centres for years. This is effective, long term contraception and good for spacing births. The main downsides are heavy menstrual bleeding and risk of infection after insertion. Other serious problems like perforation is rare.
Intra uterine hormonal system (Mirena)
It is another intrauterine system which contains some progesterone type hormone. This hormone is released slowly within the uterus and make endometrium thin. This is a great devise in terms of prevention of many gynecological conditions like menorrhagia, adenomyosis, endometriosis etc. If used in aged women it may decrease growth rate of existing fibroid and even chance of uterine cancer. It is very effective, long term and great for spacing birth especially who have heavy menstrual flow. However, it may cause oligomenorrhoea and amenorrhoea (Very little /no menstruation) which can be beneficial for anemic women. Sometimes it cause a great concern amongst the users.
The injectable contraceptive
This is basically a large dose of injectable progesterone type hormone to be injected on three monthly basis. It also confers many gynecological health benefit like endometriosis, adenomyosis, dysmenorrhea but may lower bone mineral density if used long term. This may also cause oligomenorrhoea and amenorrhoea (Very little /no menstruation) which can be beneficial for anemic women.
The vaginal hormonal ring
This is a soft ring which can be easily placed within vagina without need of a gynecologist and this liberates combination of estrogen and progesterone. One ring is effective for one month. Very effective, very low side effect, very good cycle control. Especially, women with advanced liver disease or sensitivity towards estrogen who need good cycle control will be greatly helped by this. Cost may be a limiting factor for common people.
Repeated miscarriages of pregnancy:
Miscarriages in a planned pregnancy break hearts. Repeated miscarriages can throw a women to severe depression. Miscarriage is common and happen in 15% -20 % of women. However repeated miscarriages is rare & incidence of recurrent miscarriages ( three miscarriages in a row) is about 0.35%.
Miscarriage mean death of the intrauterine fetus before 24 week of pregnancy. Most of the miscarriage happen in early gestational age ( below 13 weeks of pregnancy).However, about 1-2% miscarriages happen at 18-23 weeks of pregnancy.
Cause of recurrent miscarriage is various and complete evaluation by a competent gynecologist is needed. Even then a specific cause for miscarriage may not be found out in many cases. It is really important to keep in touch with a competent gynecologist regularly. Treatment depends on gynecological evaluation and sometimes empiric treatment is given if no cause is found. Mutual trust between you and your gynecologist is a really important factor.
Termination of pregnancy :
Termination of pregnancy sometimes needed for medical reason where there is a chromosomal anomaly or major congenital structural anomaly of fetus. In case of severe maternal disease like decompensated heart,lung ,kidney or liver disease. The decision always need to taken after counseling with the women and her partner.
The problem is many young couple often come with request of termination just because they do not want pregnancy at that particular time. This is a difficult moral dilemma for an ethical Gynecologist wheather just to comply with the request of the patient or to counsel them for long time about the downside and risks of termination. In Kolkata, I have seen women who reveled that they had multiple terminations in the past (almost as a family planning tool!) but did not use the oral contraceptive pills for fear of side effect!
Terminations can be done by medical or surgical method or in combination of both methods. Medical termination involves taking medications which can induce abortion. This can be effective if the pregnancy is early (below 9 weeks). It has less risk of infection or injury but can fail and may induce heavy bleeding with severe pain which needs admission. Surgical procedure involves putting the women to sleep and place a tube in uterus to evacuate all the pregnancy tissues. The risk involves hazards of anesthesia, failure to empty the uterus, infection and rarely injury. The good thing about surgical method is it can be done in pre scheduled time with a high chance of success rate.
What is better? Normal delivery or Caesarean?
This is an ongoing dilemma not only in you but also in the minds of gynecologists and gynecological researchers. Basically pregnancy and childbirth (whatever route) is a risk towards the women and the newborn but we need to find out the lesser evil between the two methods of childbirth in terms of immediate and long term risk.
Normal delivery is a natural process and preferred by most of the women. It is also safer for the women’s health in comparison to a major surgery like caesarean section. As a major operation, Caesarean section can cause heavy bleeding, infection of wound site, urinary bladder and reproductive tract, blood clot (thrombosis), adhesion formation in abdomen, anesthetic hazards, injury to urinary bladder etc.
Caesarean section although gynecologist controlled procedure is very common these days with reasonable safety record with advent of modern medical facilities. And we should not forget that many times cesarean section is done as a life saving procedure. In normal labour, the unborn child may get compromised because of lack of oxygen. Without proper monitoring facility hypoxia of the foetus may go unnoticed which may cause life long disability & death. However, I must say that a wellgrown baby in a good gynecologist’s hand should not be suffering from hypoxia in a normally progressing labour. Other important issue is that normal delivery may increase the long term gynecological morbidity (e.g.genital prolapse. , urinary incontinence) in the mother. There is a question on whether normal delivery affect the sexual dysfunction in later life of the women.
To draw a conclusion is very difficult on this debate as the expert gynecologists vary in their opinion on that. As my experience, normal delivery should be preferred if there is no high risk factor in the pregnancy, baby is normally grown, in normal position and proper monitoring facility is available. To be precise, Normal delivery is best if everything is normal but otherwise not.